GW1-2022-10529_Well Construction - GW1_20221121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form caa be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.wAT Z4)NEs.
FROM TO DUCRUMON
Well Contractor Name ft 0 ft
NCWC 2028-A & ft
NC Well Contractor Certification Number IS.OUTERCASING Mormrdtisat6dvtells OR LINER tf bk
FROM TO DIAMETER TFUCKNFSS MATERIAL
Ferguson's Well and Pump, LLC 62 ft ft 12 ;­ S
Company Name 16 CASIl!FG OR G;
FROM I TO I DIAMETER MUCKNESS I MATERIAL
2.Well Construction Permit#: DO�d — �� j 1 ft ft in
RV all applicable well corestruchon pernuts(1.e.County,Siate,RParimrce,etc.)
tt ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE 1MCKNFSS MATERIAL
❑Agricultural ❑ blic ft ft m
❑Geothermal(Heating/Cooling Supply) est�Water Supply(she)` ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) to*GROUT
FROM TO MATERIAL EMPLACEMENT METHOD dt AMOUNT
❑hit atetion ft 20 ft Concrete Gravity-Flow
0
Non-Water Supply Well:❑Monitoring ❑Recovery ft ft-
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediatiou i9 SAND/GRAVEL PACK<fif appHchMel
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO F MATERIAL EMPLACEMENTIAW1110D
f�
❑Aquifer Test ❑Stormwater Drainage 1 ft ft
❑Experimental Technology ❑Subsidence Control 2a DRILLING LOG tattmfi addifionsl Ac elsif
❑Geothermal(Clused Loup) ❑Tracer FROM T0____DFSLT1PT[0N(co1Gr hardne&i6soiUroclt etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft ft
ft ft
4.Date Well(s)Completed: Well mm ft ft
Sa.Well Location: ft ft
f`
L4 Hr/a-4 4 ft &
Facility/O'amer ame Facility EX(if applicable) R ft .
t.' A 7 1441 ( /"111Z V & ft
Physical Address,City,and Zip 2L REMARKS
�.nca.a2hi 9(�O l� 9 3 5 yn 1
Cpunry Parcel Identification No.(PIN) pfeseeeim
pf-aOG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.CerttBication:
(if well field,,one lat/long is sufficient)
6 &Z zll�l
S of cd n r
6.Is(are)the well(s): �rmanent or ❑Temporary
By signing Bus form,1 hereby cem;fy that the well(s)was(were)constructed an accordance_
/ with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l2AO copy of Bur record has been provitkd to the well owner.
If this is a repair,fill ors known well conslruetion b#brnra7i6n mid explain the natrme ofthe
repair wader#21 remmb section or on the back of LWfmm 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For»adAiple hyecttan or non-water supply wells ONLY with the same constntdian you can
sabnet arefomr. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 72 C (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For n-&ple wells list all depths if�e—f(e—Wk-3@20 and 2Q100') construction to the folloming:
10.Static water level below top of casing: (ft) Division of Water Quality;Information Processing Unit,
If water level is above easing,use"+" '— 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: � 0 (in.) 24b.For Inieetton Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.'.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injecdop Control Ptpgtam,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-16M
f
13a.Yield(gym) Method of test: Blowing-Rig 24c.For Water Sunnly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlodne ,Mount � � OZ. completion of well construction to the county health department of the county
where constructed
Form C�V-1 - North Carolina Department of Environment and Natural Resources—Division of Water QuWily Revised Jan.2013